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Billing and coding

Patient receives service at a discounted rate from a panel, or select group of physicians and other health care providers who participate in the program

CAREN

computerized telephone inquiry system that provides information about a patient's eligibility, and benefits.

C.O.B

program for determining which health insurer pays for services first when a subscriber is covered by more than one health care plan.

Contract Number

The alpha numeric combination assigned to the person named on the ID card. 3 character must be included on the for,

Copayment

This can be a set dollar amount based on contract benefits, or a percentage of the approved amount that the subscriber pays for medical services.

Customary Charge

The charge which the physician or other provider usually charges for specific services

Deductible

The amount that must be paid by a subscriber before an insurer begins to pay for medical services.

DENIS

Dial in Eligibility Network and Information System- computer based system that gives you access to BCBSM through the internet to obtain information on patient's eligibility, benefits and claim's status.

Dependent

person covered by the subscribers health care plan

CMS 1500

Claim form used to report services rendered for payment

HMO

Health Maintenance Organization- Patients must choose a PCP who provides services, must obtain referrals to see specialist

Master Medical

The coverage that extends and adds benefits to a patient's basic BCBS contract

Modifiers

A two character code- either 2 numbers or an alphanumeric code to further clarify information about a CPT code to the insurance carrier

NASCO

National Accounts Service Company- reprsents employers such as GM, Ford, and Chrysler to name a few

Non-Participating Physician

Physician who has not entered into a written contract to accept BCBS payments as payment in full. Patient would be responsible for the difference in the payment and the physician's charged amount

Participating Physician

Physician who has entered into a written contract with BCBS to accept the payment from BCBS as payment in full. Patient can only be charged deductibles, co pay, on non-contract benefit

Point of Service (Blue Choice)

Similar to HMO except that subscribers may recieve partial coverage for services not authorized by the PCP

PPO (Blue Preferred Plan)

Preferred Provider Organization- patients recieve services at a discounted rate from a select group of physicians and other health care providers who participate in the program. May be co pays`

Preauthorization

Process of obtaining approval for a service through the individual's insurance company by establishing that it is medically necessary